Form Sar 73 - Senior Parent Semi-Annual Income Report
Download a blank fillable Form Sar 73 - Senior Parent Semi-Annual Income Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Sar 73 - Senior Parent Semi-Annual Income Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASE NAME:
SENIOR PARENT
CASE NUMBER:
SEMI-ANNUAL INCOME REPORT
REPORT MONTH:
(Supplement to the SAR 7 - Use for unaided senior parent.)
The rules say that when a minor parent (up to age 18) gets cash aid, we must count the income of the senior parent(s) living in the same
home. We will figure how much of this income will be counted.
INSTRUCTIONS:
●
Fill in this for m and retur n it with your Semi-Annual
●
If we do not get a complete report by the 11th day of the
Eligibility/Status Repor t (SAR 7) by the 5th day of the
submission month, your cash aid and cash-based Medi-Cal may
submission month. Answer all of the questions about your
be delayed, changed or stopped.
parent(s) who lives with you.
●
If you have questions, ask your worker or call the county.
■ ■
■ ■
1.
During the Report Month did your parent(s) get income, money, or benefits, such as:
YES
NO
earnings; government benefits like Social Security, Unemployment/Disability Benefits (UIB/DIB),
Supplemental Security Income/State Supplementary Payment (SSI/SSP), worker’s compensation; railroad
retirement, veterans or other private or government disability retirement; In-Home Supportive Services
(IHSS); interest or dividends from stocks, bonds, savings account; child/spousal support; training payments;
strike benefits; cash, gifts, loans, grants, scholarships; tax refunds; Earned Income Tax Credit (EITC);
gambling/lottery winnings; rental income, rental assistance; free housing/utilities/clothing or food; insurance or
legal settlements; etc?
If “YES”, list who got the money, the source, gross amount before deductions, and actual date they got it in
the Report Month. Attach paystubs or other proof of your parent’s earnings in the Report Month. If anyone is
self-employed, list business expenses on a separate sheet of paper and attach proof of income and expenses
in the Report Month. Proof for any self-employment income or other income is needed only when it starts
and when it changes.
GROSS AMOUNT
WHO GOT THE INCOME
SOURCE OF INCOME
$
$
$
$
$
ACTUAL DATE THEY GOT IT
GROSS AMOUNT
SOURCE OF INCOME
WHO GOT THE INCOME
$
$
$
$
$
ACTUAL DATE THEY GOT IT
■ ■
■ ■
2.
Will there be any changes to this income in the next six months?
YES
NO
If “YES”, list below what change is expected. Attach any proof they may have such as, a letter from an
employer, benefit award letter, etc.
HOW AND WHEN WILL IT CHANGE?
WHOSE INCOME WILL CHANGE?
WHAT INCOME WILL CHANGE?
CERTIFICATION
I understand that if on purpose I do not report all facts, or give wrong information to get aid, I can be legally prosecuted. I can be
●
charged with committing a serious crime if I received more than $950 in aid that I am not supposed to get. And my cash aid can be
stopped for a period of time. I may be fined up to $10,000 and/or sent to jail or prison for up to 3 years.
I understand that the facts I report may result in my benefits being changed or stopped.
●
I understand that I have the right to a State Hearing on any proposed action by the County Welfare Department.
●
I declare under penalty of perjury under the laws of the United States and the State of California that the facts contained in this report
●
are true and correct and are complete.
YOU MUST SIGN AND DATE THIS REPORT AFTER THE LAST DAY OF THE MONTH OR IT WILL BE INCOMPLETE.
☛
SIGNATURE OF CASH AIDED MINOR PARENT
DATE SIGNED
COUNTY USE ONLY
SAR 73 (3/13) REQUIRED FORM - SUBSTITUTE PERMITTED
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal